Medical Service Charges--Charges for the following medical services are eligible expenses:

• nonsurgical professional services by a physician or nurse;
• radiologist or laboratory charges for X-ray or radiation therapy, diagnosis or treatment;
• rehabilitation facility charges, up to 30 days confinement per calendar year;
• one screening by low-dose mammography, beginning at age 35;
• emergency transportation in an ambulance to the nearest hospital, up to $3,000 per calendar year;
• if a tubal ligation is performed during a pregnancy or complication of pregnancy, then those charges will be considered as eligible expenses.  Tubal ligation and vasectomies performed as outpatient surgery are covered after the first year of coverage;
• one cytological screening per calendar year for women age 18 and older;
• coverage for one prostate cancer screening per calendar year for an insured person age 50 and over.

Medical Supply Charges--Charges for the following medical supplies are eligible expenses:

• prescription drugs, limited to $750 per calendar year;
• blood, blood plasma, oxygen and anesthesia and their administration;
• initial artificial limbs or eyes needed to replace natural limbs or eyes that are lost while an insured person's coverage is in force (however, no benefit will be paid for repair or replacement of artificial limbs or eyes, or other prosthetic devices);
• initial prosthetic devices required as a result of a mastectomy performed while an insured person's coverage is in force;
• casts, splints, surgical dressings, crutches, and the rental of wheelchairs, hospital beds, and other durable medical equipment;
• diabetic equipment and supplies prescribed by a physician and selfmanagement training and education including nutritional counseling whne suprevised by a licensed healthcare provider with expertise in diabetes. 

Dental & Cosmetic Charges--Treatment of sound, natural teeth due to bodily injury that occurs while the insured person's coverage is in force. 

Cosmetic or  reconstructive surgery needed to correct a bodily injury or sickness that occurs while the insured person's coverage is in force is covered.  Cosmetic or reconstructive surgery that is not medically necessary will not be covered.

Human Organ and Transplant Charges--Hospital, medical service and medical supply charges for non-experimental human organ and/or tissue transplant charges are eligible expenses.  If the insured person uses the Transplant Network, benefits will be paid up to the amount of the charges negotiated by the Network.   In addition, there is a limited travel and lodging benefit.  If the insured person elects to have the procedure performed outside the Transplant Network, up to $100,000 will be reimbursed per procedure. 

Reconstructive Breast Surgery--As a result of a mastectomy performed while coverage is in force.

Complications of Pregnancy--Complications of pregnancy covered as any other illness.  No benefits are paid for a normal pregnancy, normal childbirth, elective Cesarean Section, or elective abortion.

Emergency Room--$50 deductible per visit in addition to plan deductible, if not admitted.  If an insured person is hospital confined immediately following an emergency room visit, the emergency room deductible will not apply.

PPO Network Charges

Network Physician Office Visits--Services performed by a network physician for a symptomatic insured person in an office setting are covered up to $200 per visit, subject to a $50 per visit copayment amount.

Non-network Services--Each time an out-of-network provider (physician and/or hospital) is used, eligible chargers are reduced by an additional 20%, which does not apply to the out of pocket maximum.  Also, the office visit copay does not apply when non-network physicians are used.

If charges by a non-network provider  are incurred by an insured person due to a medical emergency, the deductible and coinsurance will be the same as if provided by a network provider.